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Umbrella Insurance
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Umbrella Fact Finding Questions
In regards to your insurance, what is most important to you? Price 
  Proper Coverage 
Approximately, when was the last time you did a review with your agent? Within the year 
  Over 2 years ago 
  Over 5 years ago 
Please rate the following in the order that you feel are most important
for you to protect?
In the event of a lawsuit, accident, or judgment would you want to: Maximize Protection 
  Assume Some Risk 
In the event of an untimely death, is it important to you that your surviving
spouse and/or children maintain the quality of life you currently have
together without debt?
Yes      No 
Would you be interested in combining your home and auto insurance
for additional savings up to 45%?
Yes      No 
Would you be interested in mortgage cancellation insurance? Yes      No 
Personal Information
First Name
Last Name
Gender Male     Female 
Date of Birth
Marital Status
Home Address
Zip Code
Best Time to Call
Best Phone Number To Reach You At
Email Address *
Single Family Dwellings Owned:
Autos Owned:
RV Owned:
Multi-Unit Buildings Owned:
Vacant Property Owned:
Motorcycles Owned:
Underwriting Information
Are any aircraft owned, leased, chartered or furnished for regular use? Yes     No 
Do any drivers have mental or physical impairments? Yes     No 
Are any premises, vehicles, watercraft, aircraft used for business? Yes     No 
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies? Yes     No 
Do you engage in any type of farming operation? Yes     No 
Do you hold any non-remunerative positions? Yes     No 
Do you employ any residence employees? Yes     No 
Any non-owned property exceeding $1,000 in value in your care, custody or control? Yes     No 
Any non-owned business or professional activities included in the primary policies? Yes     No 
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures? Yes     No 
Was any coverage declined, cancelled or non-renewed within the past 5 years? Yes     No 
Any motorcycles, mopeds or all terrain vehicles owned? Yes     No 
Any other business activities conducted from your residence or premises? Yes     No 
If yes, Please explain.
Current Coverage Information
Current Umbrella Insurance Company
Losses and Claims for the Last 5 years? Yes     No 
If yes, what is the date, amount paid and description of each loss or claim.
Liability Limit:
Additional Information, Comments, Recommendations: